Natal tooth : A Case Report and Review

Natal teeth are defined as teeth that are present in the mouth at the time of birth. It must be considered that natal and neonatal teeth are conditions of fundamental importance not only for a dental surgeon but also for a paediatrician, since their presence may lead to numerous complications. Hence the purpose of the present paper is to review and discuss its clinical features, complications and management.


Introduction
Child development from conception through the fi rst year of life is marked by many changes.Tooth eruption at about 6 months of age is a milestone both in terms of functional and psychological changes in the child's life and in emotional terms for the parents.The expectations about the eruption of the fi rst teeth are great and even greater when the teeth appear early in the oral cavity.When teeth are observed at birth or during the fi rst month of life, it evokes interest, curiosity and concern to the parents.To complicate matters further, there are various diffi culties, like pain on suckling, refusal to feed, faced by the mother and the child due to the natal tooth or teeth.
Teeth present at the time of birth are called Natal teeth.Teeth which erupt in the neonatal period that is, within thirty days of birth are Neonatal teeth.Teeth erupting beyond the natal period of thirty days (i.e.erupting within 1-3.5 months) are usually referred to as early infancy teeth 1 .The presence of teeth in newborns is uncommon, varying from 1:6000 to 1:800 cases 2. Terms such as congenital teeth, foetal teeth, pre-deciduous teeth, premature teeth, precociously erupted teeth or dentitia praecox have been used to refer this condition 3 .

The case
A 12 day-old female infant was referred to the Kannur Dental College and Hospital with complaint of two teeth in the lower jaw since birth, mother complaining of pain on suckling, and refusal to suck milk.Oral examination revealed two crowns of the teeth in the mandibular anterior region [ Fig 1], whitish opaque in color and exhibiting grade III mobility.The crown size was small; the gingiva was of normal appearance.A diagnosis of natal tooth was made and was extracted under topical anesthesia.The extracted teeth had a crown but were devoid of roots [ Fig 2] .The patient was reevaluated after two days and the recovery was uneventful.
1. Shell-shaped crown poorly fi xed to the alveolus by gingival tissue and absence of a root.
2. Solid crown poorly fi xed to the alveolus by gingival tissue and little or no root.
3. Eruption of the incisal margin of the crown through the gingival tissues.
4. Edema of gingival tissue with an unerupted but palpable tooth.
The most acceptable theory of presence of natal teeth is based upon the result of a superfi cial localization of the dental follicles, probably related to a hereditary factor 2,4 .But it is necessary to investigate the possible local or systemic factors that could be related to the eruption of natal teeth, their association with other pathologies, and the basis of differential diagnosis, in order to promote a better oral condition.It is also important to consider that natal teeth are not the only oral alteration that can be observed in neonates, remembering other lesions such as cysts and developmental disturbances.A complete oral examination is recommended in newborns, in order to establish the differential diagnosis (2,4,7) .
Clinically, the natal teeth are small or of normal size, conical or of normal shape.They may reveal an immature appearance with enamel hypoplasia and small root formation.Natal teeth may exhibit a brownyellowish or whitish opaque colour.They are attached to a pad of soft tissue above the alveolar ridge.The dimensions of the crown of these teeth are smaller than those of the primary teeth under normal conditions 6 .
Complications related to natal and neonatal teeth include discomfort during suckling, irritation and trauma to infants' tongue, sublingual ulceration (Riga-Fede disease) laceration of the mother's breast and risk of aspiration of the mobile teeth 6,7 .Prolonged gingival irritation from natal or neonatal teeth may cause localized infl ammation of the gingiva or fi brous hyperplasia1 8 .
Cysts of the dental lamina and Bohn's nodules could be confused with neonatal teeth.Another condition which should be considered is epulis, which are tumorlike growths of the gingiva, and are reactive rather than neoplastic lesions.Other differential diagnosis includes lymphangioma 1,4,8 .
Natal tooth with mobily of >1 mm of are indicated for extraction 9 .The possibility of aspirating or ingesting natal teeth is reported to be a reason for extraction of mobile teeth.. Extraction may also be needed to alleviate feeding diffi culties or complications like Riga-

Discussion
It has been observed that, natal and neonatal teeth erupt 85% in mandibular incisor region, 11% in maxillary incisor region, 3% in mandibular canine region and 1% in maxillary canine and molar region 5 .Spouge and Feasby (1966) have suggested that clinically, natal and neonatal teeth are further classifi ed according to their degree of maturity 6 :-1.A mature natal or neonatal tooth is one which is nearly or fully developed and has relatively good prognosis for maintenance.
2. The term immature natal or neonatal tooth, on the other hand, refers to a tooth with incomplete or substandard structure; it has a poor prognosis The appearance of each natal tooth into the oral cavity can be classifi ed into four categories as the teeth emerge into the oral cavity 6 :-Fede disease.Extraction may also be done if child's age is 10 days or above and child has appropriate amounts of Vitamin K in the blood The waiting period before performing extraction is to allow the commensal fl ora of the intestine to become established to produce vitamin K which is essential for production of prothrombin in liver.Therefore it is safer to wait until a child is 10 days old before extracting the tooth.
Otherwise prophylactic administration of vitamin K (0.5-1.0mg, i.m) after discussing with the pediatricianis advocated before and after extraction 1,4,9,10 .Teeth that are stable beyond four months have a good prognosis 2 .In some cases to prevent the injury to maternal breast, grinding or smoothening of the incisal edges of the teeth is also recommended 6 .

Conclusion
Natal and neonatal teeth do not appear frequently, proper evaluation and diagnosis are necessary for the best treatment option.Paediatricians are, usually, the fi rst who fi nd these teeth and early consultation with dentist can prevent complications.When teeth are supernumerary, they should be extracted.Alternatives such as smoothing the incisal edge are also recommended.Periodic follow-up by dentists are of fundamental importance, as are recommendations to the parents with respect to home dental hygiene.

Fig 1 :
Fig 1: Showing the child with Natal Teeth